Management of Acute Gastroenteritis with Severe Vomiting and Dehydration
The next step is immediate intravenous fluid resuscitation with isotonic crystalloid (lactated Ringer's or 0.9% normal saline) to correct dehydration, followed by symptomatic management with antiemetics and antimotility agents, while withholding antibiotics unless fever or bloody diarrhea develops.
Immediate Fluid Resuscitation
This patient presents with "violent" vomiting causing obvious dehydration—this constitutes complicated gastroenteritis requiring aggressive management even without fever. 1
Administer IV isotonic fluids (lactated Ringer's or normal saline) immediately to correct the dehydration deficit, as oral intake is clearly not tolerated given the severity of vomiting. 2
The goal is to restore hemodynamic stability and correct electrolyte abnormalities (even though the CMP is currently normal, ongoing losses will rapidly deplete reserves). 2
Avoid overly aggressive fluid boluses in adults without shock—moderate resuscitation prevents fluid overload while achieving adequate rehydration. 3
Antiemetic Therapy
Administer ondansetron (8 mg IV or orally) to control the severe vomiting and facilitate transition to oral rehydration once initial IV resuscitation is complete. This reduces vomiting frequency and improves oral tolerance. 4
Controlling emesis is critical to prevent further dehydration and allow oral intake for ongoing loss replacement. 4
Antimotility Management
Start loperamide at 4 mg initially, then 2 mg after each loose stool (maximum 16 mg/day) to reduce diarrhea frequency and fluid losses. 1
This is appropriate for adults with complicated diarrhea once infectious causes requiring antibiotics are excluded. 1
Antibiotic Decision-Making
Do not start antibiotics at this time because: 1
No fever is present—fever is a key indicator for empiric antibiotic therapy in complicated gastroenteritis. 1
No bloody diarrhea—the absence of dysentery makes invasive bacterial infection (Shigella, Salmonella, Campylobacter) unlikely. 5
The CT shows nonspecific enteritis without features of severe bacterial infection or colitis. 6
Reconsider antibiotics only if: fever develops, bloody diarrhea appears, or symptoms persist beyond 5 days without improvement. 1
Dietary and Ongoing Management
Once vomiting is controlled, transition to oral rehydration solution (ORS) containing 50-90 mEq/L sodium to replace ongoing losses. 2
Resume normal diet as soon as tolerated—there is no benefit to "bowel rest" and early feeding promotes intestinal recovery. 1, 2
Avoid lactose-containing products, alcohol, and high-osmolar supplements during the acute phase. 1
Monitoring Parameters
Reassess hydration status after 2-4 hours of IV therapy by examining skin turgor, mucous membranes, urine output, and vital signs. 2
Monitor for resolution of vomiting and reduction in diarrhea frequency. 1
Escalate care if: severe abdominal pain develops, bloody stools appear, mental status changes, or signs of sepsis emerge. 1
Addressing the Spice Allergy History
The recurrent pattern with Cajun spices suggests a food intolerance or hypersensitivity reaction rather than infectious gastroenteritis, though the CT finding of enteritis favors an infectious/inflammatory process this time. 1
Outpatient allergy testing should be arranged after resolution of the acute episode to identify specific triggers and prevent future episodes. 1
This does not change acute management but is important for long-term prevention. 1
Common Pitfalls to Avoid
Do not assume pancreatitis despite the history of violent vomiting—the normal lipase excludes this, and elevated lipase can occur with infectious colitis without true pancreatitis. 6, 7
Do not prescribe empiric antibiotics without fever, bloody diarrhea, or prolonged symptoms (>5 days)—this promotes resistance without benefit. 1
Do not use hypotonic IV fluids—isotonic crystalloids prevent iatrogenic hyponatremia. 2
Do not withhold food once vomiting resolves—early feeding is beneficial. 1, 2